The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea

Abstract

ABSTRACT. The aim of this prospective study was to evaluate the value of unenhanced (three-dimensional constructive interference in steady state (3D-CISS)) and contrastenhanced MR cisternography (CE-MRC) in detecting the localisation of cerebrospinal fluid (CSF) leak in patients with rhinorrhoea. 17 patients with active or suspected CSF rhinorrhoea were included in the study. 3D-CISS sequences in coronal and sagittal planes and fat-suppressed T 1 -weighted spin-echo sequences in three planes before and after intrathecal contrast media adminstration were obtained. Images were obtained of the cribriform plate and sphenoid sinus. In addition, high-resolution CT (HRCT) was performed in order to evaluate the bony elements. The leak was present in 9/17 patients with 3D-CISS and 10/17 patients with CE-MRC. The leak from the cribriform plate to the nasal cavity in six patients and from the sphenoid sinus in four patients was nicely shown by CE-MRC. Eight of those patients were surgically treated, but spontaneous regression of the symptoms in two precluded any intervention. The leak localisations shown with CE-MRC were fully compatible with surgical results. The sensitivities of HRCT, 3D-CISS and CE-MRC for showing CSF leakage were 88%, 76% and 100%, respectively. In conclusion, 3D-CISS is a non-invasive and reliable technique, and should be the first-choice method to localise CSF leak. CE-MRC is helpful in conditions when there is no leak or in complicated cases with a positive b2-transferrin measurement.

Intrathecal Gadolinium-Enhanced MR Cisternography: A Comprehensive Review

“…CT has overcome these limitations; however, both CTC and RC involve radiation exposure, which is a more important factor to consider because cisternographic studies often require consecutive or multiple acquisitions. [2][3][4][5][6] NCE-MRC derived from heavily 3D T2-weighted sequences (such as fast imaging with steady state acquisition, CISS, or sampling perfection with application optimized contrast using different flip angle evolutions) has been developed to overcome the above-mentioned limitations of CTC and RC. [3][4][5] This technique can be helpful in investigating CSF leakage and the fluid dynamics of the ventricular system.…”

“…[2][3][4][5][6] NCE-MRC derived from heavily 3D T2-weighted sequences (such as fast imaging with steady state acquisition, CISS, or sampling perfection with application optimized contrast using different flip angle evolutions) has been developed to overcome the above-mentioned limitations of CTC and RC. [3][4][5] This technique can be helpful in investigating CSF leakage and the fluid dynamics of the ventricular system. [7][8][9][10] High contrast-to-noise ratio, multiplanar evaluation of volumetric data, and thin-section image acquisition are the main advantages of NCE-MRC.…”

“…11 Moreover, it is noninvasive, and it does not require radiation exposure or intrathecal contrast material administration. 4 Although NCE-MRC has several advantages, it can only provide morphologic information different from that in other cisternographic studies. 9,10 CE-MRC can provide both physiologic and morphologic information, unlike NCE-MRC.…”

“…Intrathecal Gd injection is not approved by the FDA, though its safety has been reported in several pilot studies in Europe. [2][3][4]6,[9][10][11][12][13][14] Tolerance and dose limits of intrathecal Gd injection were established in animal model studies, and different Gd compounds (eg, gadodiamide, gadobenate dimeglumine, and Gd-DTPA) were compared in different experimental animal protocols. 5,[14][15][16][17] High-dose intraventricular Gd injection was reported to result in behavioral and neurologic disturbances (focal seizures, ataxia, latent tremor) with histopathologic changes (loss of oligodendroglia, astrocytic hypertrophy, and eosinophilia); on the other hand, it was concluded that these changes and distur-bance did not occur if the total injected dose wasϽ15 mL (3.3 mmol/g).…”

Repair of a traumatic subarachnoid-pleural fistula with the percutaneous injection of fibrin glue in a 2-year-old

“…23 While CT myelography is the imaging modality of choice to visualize SPFs, MRI with thin-section T2-weighted sequences (such as CISS) and contrast-enhanced cisternography have become reasonable alternatives as they have been reported to have 76% and 100% sensitivity, respectively, in detecting CSF leaks. 2 Optimal treatment for SPF remains controversial; however, there is consensus that such fistulas are unlikely to resolve spontaneously. 7 The intrathoracic pressure ranges from -5 to -7.5 cm H 2 O, whereas the intradural pressure is between +10 to +15 cm H 2 O; thus, this pressure gradient plays a critical role in maintaining fistula patency.…”